Alcohol or substance abuse problems are strongly associated with suicidal behavior [1, 2]. According to statistical data, the risk of suicide attempts in patients with alcohol and drug abuse disorders is estimated as 50% higher than in the general population [3, 4]. Approximately 25% to 35% of all suicide attempts from the general population are associated with alcohol abuse as a contributing factor [1, 5]. On the other hand, people who commit suicide under alcohol or drug consumption attempt to use means that leave them small chances of survival [6]. These data qualify people with alcohol or drug abuse as being at-risk, and justify the efforts of mental heath practitioners and related professionals to develop and implement evidence-based strategies to prevent suicide in this population.
In the World Health Organization documents [7, 8], suicide is conceptualized as a multidimensional disorder, the result a complex interaction of biological, psychological, sociological and environmental factors. Suicide prevention is a very complex task in the general population as well as alcohol or drug dependent individuals. It involves various activities ranging from a continuous preoccupation in communities to ensure a certain quality of life for their members - through effective diagnostic and treatment of psychiatric disorders -, to assessment of suicidal risk and implementation of specific preventive measures to reduce this risk (from the control of environmental factors and limitation of access to specific methods to commit suicide, to psychological interventions designated to improve problem solving abilities, coping skills or social adaptation). An effective strategy to prevent suicide requires the collaborative efforts of various persons and groups, including mental health professionals, general physicians, clinicians, counselors, social workers, educators, media communicators, families and communities [7].
From both the World Health Organization (WHO) and National Institute of Mental Health (NIMH) perspective, the concept of prevention in mental health goes beyond a set of actions taken before the initial onset of a disorder. The definition of prevention has been extended to integrate interventions addressed to the whole health-illness continuum: interventions designated to reduce the risk and incidence of a disorder, severity, duration, its relapses, the disability associated with it [9, 10]. In relationship with their aims, preventive strategies could be classified as: primary prevention (when the target is to reduce the number of new cases of a specific disorder), secondary prevention (which refers to interventions aiming to reduce the prevalence of the disorder), and tertiary prevention (interventions undertaken to diminish its consequences). From a cost-benefit analysis point of view (the cost, risk or discomfort of the preventive strategy versus its positive effects), prevention in mental health has been divided in the following three categories: universal prevention (targeting the general public or a whole population group, regardless of their risk to develop a mental disorder), selective prevention (targeting subgroups or individuals of the population whose risk of developing a mental disorder is estimated as significantly higher compared with the rest of the population), and indicated prevention (targeting persons at high risk of mental disorder) [9].
Primary Prevention
Primary prevention of suicide refers to measures directed at a large population in order to prevent the occurrence of new cases of suicidal acts. These measures include an effective control of alcohol and drug abuse problems and other psychiatric disorders (studies conducted in different countries have shown an overall prevalence of mental disorders situated around 90% in the cases of completed suicide; depression, alcohol and drug abuse and personality disorders are the most incriminated in this etiology) [4, 11].
At the same time, primary prevention can be accomplished through measures addressed to the environmental and individual factors, which non-specifically contribute to the etiology of suicide. I mention here all active measures to reduce social exclusion and social alienation, to control poverty and incurable physical illnesses, to improve peoples' quality of life, to help them to avoid and to change at-risk attitudes and behaviors. Such generous objectives are feasible through a wide range of activities starting with informational campaigns, counseling, guidance and training sessions in the communities, and leading to sustained social, economical and legislative measures.
Secondary Prevention
Secondary prevention of suicide refers to specific measures to reduce its incidence in vulnerable groups. Identification of the groups at risk represents a necessary step in secondary prevention, which allows the development and implementation of more adapted, reliable and efficient preventive strategies.
As mentioned earlier, available statistical data indicate that the individuals with substance abuse problems present a higher risk of suicidal behavior [3-5]. An accurate prediction of the occurrence of suicidal acts is still difficult to accomplish, since they are relatively infrequent events [11], even in these at-risk populations (the suicide rate among the people with alcohol abuse disorders has been estimated as 5% in the U. S. [2]). Alcohol or drug abuse is not the only risk factor for suicide attempts. In every particular case, the suicidal behavior is the outcome of complex psycho-physiological mechanisms, triggered by social, biological or various environmental influences [4, 12].
There is a certain difference between suicidal thoughts, suicide attempts and suicide completion. Practically, only some of the people who present suicidal ideation commit suicide. The overcautious assumption that every individual who reports suicidal ideation is at risk of suicide inevitably generates false positive predictions and may lead to unnecessary limitation of the patients' rights and liberties as well as a wasting of medical resources. On the other hand, the opposite extreme attitude, characterized by the underestimation of the patients' complains and suicidal thoughts, generates false negative predictions and may endanger the patients' safety [7].
Secondary prevention of suicide in individuals with alcohol and/or drug abuse implies the following main objectives/activities:
treating the primary psychiatric condition - alcohol or substance abuse;
an accurate evaluation of the imminent and short-term suicidal risk with the identification of the most vulnerable cases;
implementation of specific strategies in order to reduce the suicidal risk (treating the comorbide disorders, controlling depression and impulsivity, limitation of access to potentially lethal means, cognitive restructuring, enhancing social support and communication, etc.).
Assessment of the Risk Factors for Suicidal Behavior in Individuals with Alcohol and/or Drug Abuse
The relationship between alcohol or drug abuse and suicidal behavior is complex, being mediated by a number of independent and interrelated biological, psychological, social and situational variables, which in their turn represent other important risk factors for suicide (e. g. depressive mood, lack of family support, poor social insertion, financial problems, poor physical health, impulsivity, lack of control, inclination to engage in high risk behaviors). There are individual cases when some of these variables play a causal role for the addictive behavior; for example, a person can motivate his/her drinking behavior as a cure for his intense feelings of sadness or loneliness. On the other hand, the alcohol or drug consumption itself may lead to financial and social problems, depression, various somatic illnesses, impaired mental and behavioral control, etc (Figure 1). Suicide risk increases as other risk factors add to alcohol or drug consumption
In assessing the suicidal risk for the patients with alcohol or drug abuse, the clinician should carefully consider the following categories of factors: severity/history of abuse, depression and associated mental disorders, the existence of previous suicide attempts, suicidal ideation, plan or intent, impulsivity and aggression, the presence of physical illnesses, negative life events, and other significant situational variables. In each particular case, the suicidal risk is increased as more of these factors are added.
Depression, Severity of Substance Abuse, and Associated Mental Disorders
Studies conducted in the U. S. and Europe have indicated that over 90% of the people who committed suicide had an associated mental disorder, the most incriminated being clinical depression and substance abuse [2, 4, 6]. According to some estimations, suicide attempts are 20 times more probable in depressed patients compared with the general population [5], and the comorbid association of depression with alcoholism and/or substance abuse dramatically increases suicidal risk [3, 13, 14]. Hopelessness is the dimension of depression most frequently related to suicidal behavior in literature [6, 12].
Among alcohol dependent individuals, increased age, a long history of chronic refractory and severe alcoholism, or additional substance abuse are associated with greater suicidal risk [12, 15]. The comorbidity of major depression, alcoholism and cocaine abuse appears to be particularly associated with suicidal behavior [16, 17]. The positive correlation between alcohol or drug abuse, depression and suicide argues for the necessity of a comprehensive approach to suicide prevention, taking into consideration both the treatment of substance abuse and depression.
Figure 1. A multi-pathway description of the relationship between alcohol/drug abuse and suicidal behavior.
In fact, the relationship between alcoholism and depression has proved to be very robust and complex, being explained through various psychological, environmental, neurochemical or genetic mechanisms [18, 19]. Some studies argue for a common genetic condition that makes the individuals vulnerable to both depression and alcoholism [20], while others emphasize the role of vicarious learning in this comorbidity. For example, an individual who observes during childhood that his father drinks alcohol to feel better when he has problems or failures is prone to adopt the same behavior later in life when confronted with the same kind of obstacles. On the other hand, there are people who simply use alcohol or illicit drugs to solve their depressive states. According to a number of studies, this often leads to a vicious cycle because sustained heavy alcohol abuse may trigger neurochemical mechanisms that have significant depressant effects [12, 21].
Antisocial and borderline personality disorder, schizophrenia (especially during the remission periods), anxiety/panic disorder, bipolar disorder are other psychiatric conditions that clinicians need to efficiently diagnose and treat because they may increase the suicidal risk, especially when comorbid with depression and alcohol abuse.
History of Suicide Attempt(s)
According to statistical data, previous suicide attempts significantly increase the actual suicidal risk [4, 5]. The existence of previous suicide attempt(s) is considered by some authors one of the best predictors of actual suicidal risk in individuals with alcohol/substance abuse [15, 22]. It has been estimated that 20%-30% of the people who commit suicide have made a previous suicide attempt [5]. In the assessment interview, special attention should be given to the potential lethality of the method chosen by the patient, to the triggered events and to the circumstances in which past attempts occurred (depressive state, feelings of despair, hopelessness, guilt, loneliness, divorce or job loss).
Family history of suicide is also a risk factor for the suicidal behavior: empirical data shows that a significant proportion of alcohol dependent individuals who attempted suicide reported that a first- or second-degree relative had committed suicide [23].
Suicidal Ideation, Plan and Intent
It is true that not all people who have had suicidal thoughts commit suicide but especially in the case of individuals with alcohol or drug abuse this risk factor should not be ignored. All these individuals are recommended to be evaluated for suicidal ideation, especially when they have recently suffered a relapse, unemployment, separation or divorce, or if they present symptoms of depression. Studies have shown that a large number of people with alcohol or drug abuse report suicidal ideation, especially at the end of a binge or in the early phase of withdrawal [7, 22, 24].
The physician or mental health specialist has the role to establish a professional and trustful relationship with any patient at risk, and asses his/her suicidal ideation. There is a myth that people who talk about their suicidal intent rarely commit suicide; in reality, many of them give some clues or warning before passing on to action. Another myth is that by asking vulnerable patients about their suicidal intentions, the physician involuntarily suggests them a solution, which might provoke the suicidal act; in reality, many patients experience considerable relief and feel understood after discussing about their thoughts with a specialist. The suicidal intent is particularly difficult to asses in the cases when patients who have a firm intention to kill themselves deliberately deny their plans. An increased attention has also to be paid in cases when a patient at risk, who has been anxious and agitated for a period of time, unexpectedly looks calm and relaxed; this state could be the consequence of the difficult decision he/she has made to end his/her life [7].
The suicidal risk increases with the frequency, persistence and mental elaboration of suicidal ideation, in particular when suicidal ideation is associated with hopelessness or comorbide depression [22]. This risk is significantly higher when the patient has an established plan of actions and/or a suicidal intent.
Impulsivity and Aggression
In most cases, suicidal behavior may be considered an impulsive act of aggression oriented toward the self [22]. Impulsivity and aggression are major risk factors for suicide, in particular among the individuals with alcoholism, substance abuse and other psychiatric conditions [6, 22, 25]. A considerable amount of research demonstrates a strong correlation between alcohol or substance abuse and aggression-impulsivity traits (the comorbide constellation of aggression, impulsivity, alcoholism and/or substance abuse, found in many clinical studies, has been described as a "desinhibitory syndrome" [26, 27]). For example, alcohol consumption has been estimated to be involved in more than 50% of the crimes committed with violence and in 86% of all murders [27, 28]. According to Koller and his colleagues [29], alcohol-dependent individuals with a history of violent suicide attempts show an increased incidence of aggressive behavior during lifetime and higher scores on aggressive-impulsive traits. Compared with depressed patients without alcohol abuse, individuals with a history of alcohol abuse and comorbide depression have higher aggression and impulsivity, and more frequently report suicide attempts, childhood abuse or tobacco smoking [6, 12, 30]. Not only the chronic consumption of alcohol, but also acute alcohol use is associated with suicide; the blood tests performed to the people who have committed suicide frequently indicate the presence of alcohol (in approximately 33%-69% of the cases) [1, 2]. Probably due to its disinhibitory effects, associated with the rise of aggression and impulsivity, alcohol consumption may increase the suicidal risk even for the people with no previous psychiatric history [24].
Meta-analytical investigations conclude that the alcohol - aggression relationship is causal and not simply correlational [25, 31]. According to Pihl and Lemarquand [30] acute alcohol intoxication can lead to aggressive behavior by three possible pathways (behavioral effects): potentiation, disinhibition and disorganization, all of these effects being neurophysiologically mediated by serotonergic mechanisms. Potentiation refers to a facilitation of behavioral responses to cues of reward, and an inhibition of behavioral responses to cues of punishment, which promotes exploration of the environment and approach behavior, minimizing the possible danger or threats. At the same time, the potentiation effect of alcohol (as well as of other stimulants, like amphetamine or cocaine) consists in a direct enhancement of aggression. The disinhibition effect is related to anxiety: anxiety has an inhibitive effect on aggression; alcohol has an anxiolytic effect and disinhibits the learned responses of aggression. Third, alcohol consumption consists in a disorganization of the higher-order cognitive functions (especially executive functions), impairing the capacity of the individual to consider the future consequences of his/her acts, which directly increases the likelihood of impulsivity and aggressive behavior.
Serotonin activity (the neurotransmitter 5-HT being particularly involved) mediates the effects of alcohol on aggression [31, 32]. A number of studies demonstrate that acute alcohol consumption transiently increases central 5-HT functioning, while chronic consumption decreases it. Low 5-HT functioning is associated with a propensity toward disinhibited behavior, alcohol preference and intake, which facilitate aggression and impulsivity. Research found the presence of low serotonin activity in suicidal behavior, aggression and alcoholism, leading to the conclusion that serotonergic mechanisms underlie all these problems [6, 12, 31, 32].
Physical Illnesses, Negative Life Events, Demographic and Situational Variables
The comorbidity of a terminal, painful or debilitating physical illness with substance abuse and/or depression significantly increases the suicidal risk. A number of studies have shown an increased risk of suicide in patients with cancer, immunodeficiency syndrome (AIDS), head injuries, severe neurological illnesses, physical inabilities, insomnia, etc [4, 22].
For people with alcohol or drug abuse, old age, living alone, divorce or recent loss of someone close, financial problems or job loss, depression associated with social isolation, presence of stressful life events, easy access to highly lethal means of suicide (e. g. fire arms or drugs) are risk factors which can lead to suicidal behavior [12, 22, 24, 25]. Many studies indicate that most suicide victims with a history of alcohol misuse are men. This finding does not reflect any particular vulnerability of men to the suicide-promoting effects of alcohol, but it can be explained through the higher prevalence of alcohol misuse among men compared with women in the general population [25, 33]. In fact, female alcohol abusers are more at risk of suicidal behavior compared with men [33, 34], probably because they are more exposed to social stigmatization.
Especially in adolescence, some problems from the past such as loss of a parent during childhood, sexual abuse, a history of neglect, violence or alcohol/substance abuse manifested by one of the parents, are likely to lead to alcohol/substance abuse as a (maladaptive) coping response; associated with depression, rigid thinking or emotional vulnerability, they may significantly increase the suicidal risk [35].
The availability of highly lethal means of suicide (such as fire arms or potentially harmful medication) may not influence the rate of suicide attempts in the general population, but it certainly influences the rate of survival from suicide. When the access to highly lethal methods of suicide is difficult, people are likely to use less lethal methods, improving their chances of survival. Due to the well-known emotional and cognitive effects of consumption, people with alcohol or drug abuse are more likely to use highly lethal methods of suicide if available, increasing the proportion of completed suicide/suicide attempts, compared with the general population [36].
Alcohol or drug abuse is considered both a major predispositioning and a precipitating risk factor for suicidal behavior. Chronic alcohol/drug abuse increases the suicidal risk through its effects of inducing negative affect and hopelessness, lowered self-esteem, and negative life events (divorce, work problems, social isolation). According to some authors, acute alcohol/drug abuse is more significant in relation to suicide than chronic abuse [24]. Alcohol or substance abuse may precipitate suicidal behavior through its depressogenic effects (if low doses of alcohol may ameliorate negative states, higher doses produce depressant effects, often leading to spontaneous suicidal ideation), impaired problem solving abilities and constricted thinking, increased aggression/impulsivity, or alcohol myopia (narrowing attention to the immediate crisis or affective state) [12, 25].
In the assessment of suicidal risk the protective factors should not be ignored. Protective factors include: effective treatment for associated mental disorders (including alcoholism or substance abuse), good health, easy access to medical and counseling services, the capacity to ask for help when necessary, problem solving abilities, good coping skills, strong connections with the family members and feelings of responsibility toward them, community appreciation and support, moral, cultural and religious beliefs against suicide, fear of death [37].
SYNTHESIS: Guidelines for the evaluation of suicidal risk for the patient with alcohol and/or drug abuse [adaptation after 22, 7]
Screen for alcohol or drug abuse (use clinical interviews, questionnaires, laboratory tests); evaluate the history and severity of consumption, abstinence attempts and relapses
Screen for associated mental disorders or other psychiatric conditions (e.g. major depression, borderline personality disorder, schizophrenia, manic depression, impulsive and antisocial behavior, anxiety disorders)
Perform a mental status examination, with emphasis on mood, affect and judgment
Investigate the existence of actual or past suicidal ideation, plan or intent, previous suicide attempts, family history of suicide attempts, access to lethal means
Identify symptoms associated with suicide (hopelessness, anhedonia, psychomotor agitation or extreme passivity, insomnia, impaired concentration, anxiety)
Investigate the severity of depression
Assess the impulsivity and aggression
Review other risk factors associated with suicide (associated physical illnesses, negative life events, job loss and financial problems, bereavement, loneliness and lack of social support, low self-esteem, feelings of guilt, presence of family violence and disruption)
Assess protective factors
Interview family or significant others
Synthesize and formulate a prevention/intervention plan
Management of the Suicidal Risk in Individuals with Alcohol and/or Drug Abuse
First Actions in Primary Care
The assessment of suicidal risk, which is practically recommended to be performed for every individual with alcoholism and/or drug abuse, is a first necessary step in the development of a coherent plan to manage the risk. During the assessment phase, family doctors, psychiatrists, social workers or other professionals in contact with people with alcohol/drug abuse play the leading role. Various assessment techniques are utilized: from medical exams and laboratory tests, to detailed inquires, interviews and questionnaires.
Depending on the assessed level of suicidal risk, the necessary level of care is established for every person. If the suicidal risk is appreciated as low - for example, when the person has a satisfactory degree of impulse/abuse control, rational thinking and good social support, then he/she can be treated as outpatient.
For the people with suicidal ideation, one of the useful and frequently employed methods in outpatient care is a "no-harm contract". In the particular case of people with alcohol/drug abuse and suicidal ideation, this contract could be adapted, adding a "non-abuse" section. The method is appropriate only for the patients who are able to understand the terms of the contract and who have control over their actions. The contract has the form of a set of clearly formulated statements, written and signed, or verbally agreed by the person at risk in the presence of the clinician or therapist, and its main role is to solidify the therapeutic alliance. The negotiation of the contract can promote discussion on patient's worries, problems or other relevant issues. In the contract, the patient agrees not to use alcohol or drugs, not to harm him/herself over a specific period of time, and to contact the physician if the situation becomes difficult to control without help. The contract is made for a short period (24 or 48 hours), and it is renewed once the stipulated period ends. It is accompanied by follow-up visits and/or telephonic contacts. The recommendation is to involve the patient's family in the negotiation and implementation of the contract; they could play an important role to monitor and sustain the patient [22, 38].
Constant evaluation over time by a specialist and social support are key elements in outpatient care. The available support systems should be identified in the patient's environment: family members, relatives, friends, colleagues, counselors, whose help the specialist should request.
It should be mentioned that, in general, patients with alcohol/drug abuse are able to contract for safety only after they have been detoxified. In most cases, before specifically addressing suicidal ideation, they should be referred to specialized centers for alcohol/drug abuse. If the specialist appreciates that certain personality factors, tensions or disturbed relations within the patient's family or his/her social environment could perpetuate suicidal ideation, the patient should also be referred for individual or family therapy.
If the suicidal risk is appreciated as moderate - for example, when the person has a persistent feeling of hopelessness associated with moderate alcohol abuse, he/she should be referred to psychiatric care. In this situation, the physician should take the time and carefully explain to the patient the reason for the referral, assure him/her that the pharmacological and psychological therapies are effective and these are the best option in his/her case, respond to the patient's anxieties about stigma and psychotropic medication, emphasize that their professional relationship continues and that referral does not mean abandonment [7].
For the people with high suicidal risk - for example, people who have chronic dependence, depression and a suicidal plan, or people with a history of suicide attempts, recurrent alcohol dependence and recent social stressors, hospitalization is mandatory. Among the indications for immediate hospitalization are: chronic alcohol abuse with severe depression, recurrent thoughts of suicide, high level of intent to die in the immediate future, psychomotor agitation and a low capacity of impulse control, existence of a plan to use a violent and immediate lethal method [7, 22]. In this case, the family should be informed about the decision. Because the admission in hospital does not automatically reduce the suicidal risk, the patients with acute suicidal risk should be kept under constant observation to ensure their safety. If the patient at risk or his family refuses hospitalization, the physician is confronted with the difficult situation to consider the involuntary admission in the hospital. In most U. S. States, a patient who refuses hospitalization could be voluntarily committed if he/she: presents an imminent danger to self and others, and an inability to care for him/herself [22, 39].
According to the World Health Organization resources for general physicians [7], every patient with alcohol and/or drug abuse should be evaluated for suicidal risk and carefully monitored. It is true that in absence of definite criteria, in many cases physicians should take into account their clinical intuition when they decide for outpatient care or hospitalization. Being the result of a complicated array of factors, suicidal behavior is still difficult to predict with a satisfactory accuracy [11].
Psychosocial Interventions
Various psychosocial interventions proved to be efficient in treating alcohol/drug abuse, depression, suicidal ideation, or other psychiatric conditions associated with suicidal risk. These include: cognitive behavioral and rational emotive interventions (e. g. cognitive restructuring, problem-solving and coping skills training, disputation of irrational thoughts), dialectical behavior interventions (e. g. emotion regulation, self-soothing, distraction tactics), psycho-educational interventions (e.g. collaborative goal-setting), motivational interviewing techniques, group and family therapy, counseling and support.
A particular emphasis in psychotherapy when working with substance abuse individuals who already have a suicidal intent or a suicidal plan should be put on the therapeutic alliance. In many cases, these patients have a poor motivation to collaborate in therapy, they are non-compliant with the treatment plan, and often show anti-therapeutic behavior (i. e. arrive late or miss the sessions, deny the problems, present low distress tolerance). In these circumstances, therapists have to show flexibility in organizing the sessions, and they have to collaborate with the patient and his/her family to anticipate and address the potential barriers to compliance [40]. The collaborative alliance with the patient's family always has a significant contribution to therapeutic success.
The core psychotherapeutic tasks for the patients with alcohol/drug abuse and suicidal risk could be summarized as follows: treat the alcohol/drug abuse; screen and address the associated psychiatric conditions which constitute risk factors for suicide (i. e. depression or personality disorders); address suicidal ideation or suicidal plan, carefully monitoring the risk; address cognitive and emotional conditions such as catastrophic or dichotomic thinking, aggression, impulsivity and lack of behavioral control, low self-esteem, feelings of guilt, hopelessness and helplessness; teach adequate problem solving strategies and coping skills; work with the patient to enhance psychosocial support and create an actively supportive environment, communicate realistic hope and progressively encourage the patient's independence and self-efficacy, explore the protective factors and emphasize the patient's strengths, communicate care and ensure support.
Pharmacological Treatment
Several systematic and well-controlled studies demonstrate that selective serotonergic antidepressants (SSRI) are efficient for treating depressive symptoms in alcoholics with comorbide major depression as well as for reducing alcohol abuse [41-44]. At the same time, SSRI present the advantage of a reduced toxicity in overdose (compared for example with the tricyclic antidepressants); this quality recommends them as a safer method of treatment for suicidal depressed alcoholics [17]. The cyclic antidepressants have proven to be efficient for treating the depressive symptoms in alcohol abusers with comorbide depression, but their effects on alcohol consumption is less clear [17, 45-47]. Electroconvulsive treatment, benzodiazepines and neuroleptics have been generally indicated as having positive effects in the treatment of suicidal patients, but their effects have not been tested on the subgroup of suicidal patients with comorbide alcohol and/or drug abuse.
A review of clinical studies available in literature has led Cornelius and his colleagues [17] to the critical observation that there is only little specific evidence regarding the effective medication for people with associated suicidal behavior, depression and alcohol/drug abuse, despite the high frequency of this comorbidity. In many practical cases, the therapeutical approaches for these patients address each pathological condition in an independent manner, ignoring any possible factor interactions. Future research has to bring further clarifications on this aspect, exploring new/alternative treatment options.
Tertiary Prevention
Tertiary prevention includes measures addressed to the individuals with alcohol/drug abuse and a history of suicide attempt(s). This category of people needs special attention, given the fact that, according to empirical data, previous suicide attempt(s) is one of the best predictors of suicidal risk in individuals with alcohol/drug abuse [4, 15, 22]. Tertiary prevention aims both to limit the damage produced by the performed suicide attempt(s) and to prevent future suicidal behavior. It includes crisis interventions, a set of specific measures taken immediately after the suicide attempt, as well as assessment, rehabilitation and follow-up measures.
Because those who have attempted suicide may have serious somatic pathologies (like broken bones, brain damage, organ injuries), depression and other mental problems, clinicians and mental health professionals collaborate for their rehabilitation. Another important aspect is that, when suicide occurs, family members and friends may feel shame, shock, anger, guilt or depression, and due to the social stigma that still surrounds suicide and substance abuse, they often prefer to keep silence about their problems and refuse specialized assistance. Empirical studies have shown that a history of suicide attempt(s) in the family significantly increases the suicidal risk to other members [23]. Thus, it is recommended that the family members of a suicidal patient always be carefully evaluated for suicidal risk; they should also benefit from all the available support of the community.
Conclusion
Suicide is still the eleventh cause of death in the U. S. [10] and its strong association with alcohol and/or drug abuse is widely recognized [1-3, 6]. Prevention of suicidal behavior is a complex activity, involving population-based approaches and more specific actions targeting higher risk groups and individuals.
In this chapter, the preventive strategies have been structured in three sections: primary prevention, secondary prevention and tertiary prevention. Primary prevention includes actions addressed to the whole population, such as the control of alcohol/drug consumption, the efficient treatment of mental disorders, restricted access to guns, or a wide range of actions destined to improve the quality of life. Secondary prevention implies the assessment of risk and protective factors in substance-dependent individuals and the management of suicidal risk. Tertiary prevention refers to protective measures necessary for the people who have already had a suicide attempt. An integrated approach with actions at all these three levels probably is the best option.
According to the white paper of the U. S. Department of Health and Human Services - Substance Abuse and Mental Health Services Administration (SAMHSA) [4], a reliable prevention approach involves the following steps: identification of the problem, identification of risk and protective factors, development, implementation and evaluation of interventions and dissemination of evidence-based practices. A literature review on the prevention of suicidal behavior in alcohol and/or drug abuse has led to the conclusion that much progress has been made on the conceptualization and identification of the risk and protective factors, even if "further research is needed to transform suicide prediction into science" [48]. Instead, there is a remarkable lack of controlled studies regarding evidence-based practices.
